Healthcare Provider Details

I. General information

NPI: 1346629151
Provider Name (Legal Business Name): MEAGAN BRIANNE HUMPHRIES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD BOX 100371
GAINESVILLE FL
32610-3001
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100371
GAINESVILLE FL
32610-3001
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0301
  • Fax: 352-265-0627
Mailing address:
  • Phone: 352-265-0301
  • Fax: 352-265-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108736
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: